"Family Planning”: An Online Evidence-based Course 2021

Raqibat Idris, MBBS, DO, MPH

Geneva Foundation for Medical Education and Research
Contraceptive methods
Part 1 - Combined hormonal contraceptives
Outline and objectives
•Description of the method
•Mechanism of action
•Effectiveness
•Benefits and side effects
•Eligibility criteria
•Interventions for associated effects

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Methods
Combined hormonal contraceptives
1.Combined oral contraceptives (COCs)
2.Combined injectable contraceptives (CICs)
3.Combined contraceptive patch
4.Combined contraceptive vaginal ring (CVR)

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 Comparing Effectiveness of Family Planning Methods

More effective
Less than 1 pregnancy per
How to make your
100 women in one year method more effective
Implants, IUD, female sterilization:
After procedure, little or nothing to do or
remember
Vasectomy: Use another method for first
3 months
Injectables: Get repeat injections on time
Lactational Amenorrhea Method (for 6 months):
Breastfeed often, day and night
Pills: Take a pill each day
Patch, ring: Keep in place, change on time

Male condoms, diaphragm: Use correctly every

time you have sex
Fertility awareness methods: Abstain or use
condoms on fertile days. Standard Days Method
and Two-Day Method may be easier to use.

Female condoms, withdrawal, spermicides:

Use correctly every time you have sex
Less effective
About 30 pregnancies per
100 women in one year

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Combined oral
contraceptive pills (COCS)

5
What are COCs? Traits and types
COCs are pills that contain low doses of 2 hormones, a progestin and an
estrogen like the natural hormones progesterone and estrogen in
a woman’s body. They are also called “the Pill,” low-dose combined pills,
OCPs, and OCs.
Traits and types

Content Combination of two hormones: estrogen and progestin

Phasic Monophasic, biphasic, triphasic

Dose Low-dose: 30-35 µg of estrogen (common), 20 µg or less

(rare in most places)

21: all active pills

(7-day break between packs)
Pills per pack
28: 21 active + 7 inactive pills
(no break between packs)

Family Planning: A Global Handbook for Providers (3rd Edition, 2018) 6

Table adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COCs: Mechanism of action

Suppresses
hormones
responsible for
ovulation

Thickens
cervical mucus to
block sperm

COCs have no effect on an existing pregnancy.

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Combined oral contraceptives (COCs):
Effectiveness
Spermicides
Female Condoms
Standard Days Method
Male Condoms
Progestin-only Pills
COCs
Progestin-only Injectables
LAM (6 months)
Copper-IUD
LNG-IUD
Tubal Ligation
Vasectomy
Implants

First-Year Pregnancy Rate per 100 Women

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COCs: Characteristics
• Most women can safely use • Less effective when not used
the pill correctly (91%)
• Safe and more than 99% • Require taking a pill every
effective if used correctly day
• Can be stopped at any time • Do not provide protection
• No delay in return to fertility from STIs/HIV
• Are controlled by the woman • Have side effects
• Do not interfere with sex
• Have some health risks (rare)
• Have health benefits

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
 COCs: Health benefits
Menstrual Others
• Decreased amount of flow • Protection from Risks of pregnancy,
and fewer days of bleeding; ovarian cancer and endometrial
no bleeding (less common) cancer and symptomatic PID

• Regular, predictable • Reduced risk of ovarian cysts and

menstrual cycles iron-deficiency anemia

• Reduced pain and cramps • Decreased symptoms of

during menses endometriosis (pelvic pain, irregular
bleeding)
• Reduced pain at time of
ovulation • Decreased symptoms of polycystic
ovarian syndrome (irregular bleeding,
acne, excess hair on face or body)
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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
No overall increase in breast cancer risk for
COC users
Analysis of a large number of studies:
• No overall increase in breast cancer risk among women who
had ever used COCs
• Current use and use within past 10 years: very slight increase
in risk
o May be due to early diagnosis or accelerated growth of pre-
existing tumors
More recent study:
• No increase in breast cancer risk regardless of age, estrogen
dose, ethnicity, or family history of breast cancer

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
 Relative risk for breast cancer among COC
users and non-users
Relative Risk Log Scale
10

Increased
Risk
1.0 1.24 1.16 1.07 1.01
[1.15–1.33] [1.08–1.23] [1.02–1.13] [0.96–1.05]

1 No Effect

Protective
Effect
[95% Confidence Interval]
0.1

Non- Current 1–4 yrs after 5–9 yrs after 10+ yrs
users COC stopping stopping after
users stopping

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Protective effect of COC use on ovarian and
endometrial cancer
Lifetime risk of acquiring ovarian or endometrial cancer after 8+ years of COC use
Number per 100 women
100
10 Reduces
Ovarian Cancer Endometrial Cancer
Non COC users Non COC users risk by more
8 COC users COC users than 50%
Protection
6 develops after
12 months of
4 use and is
3.1 present for at
least 15 years
2 1.7
1.2
0.7 0.6 0.7 0.6 Source: Petitti and
0.2 0.3 0.2 0.4 Porterfield,
0.1
1992; CASH
0 Study 1987.
United States Costa Rica China

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COCs and cervical cancer
• Cervical cancer is caused by certain types of human
papillomavirus (HPV).
• Some increase in risk among women with HPV and others who
use COCs more than 5 years.
o Risk of cervical cancer goes back to baseline after 10 years of
non-use
• Cervical cancer rates in women of reproductive age are low. Risk
of cervical cancer at this age group is low compared to mortality
and morbidities associated with pregnancy.

COC users should follow the same cervical cancer

screening schedule as other women.
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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COCs: Risk of blood clots is limited
• COCs may slightly increase risk of blood clots:
• Stroke • Deep vein thrombosis
• Heart attack • Pulmonary embolism

• Risk is concentrated among women who have additional

risk factors, such as:
• Hypertension
• Diabetes
• Smoking

Stop COCs immediately if a blood clot develops.

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COC users and risk of blood clots
Estimates of venous thromboembolism per 100,000 woman-years

Incidence Relative Risk

Young women in the general
population 4–5 1

Low-dose COCs 12–20 3–4

High-dose COCs 24–50 6–10
Pregnant women 48–60 12

Pregnancy presents a higher risk of blood clots

than do COCs.

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COC users and risk of heart attack
Estimated number of heart attacks per million woman-years
Characteristic Age 20-24 Age 30-34 Age 40-44

Healthy non-COC user 0.14 1.7 21.3

Healthy COC user 0.34 4.2 53.2

COC user who smokes 1.6 20.4 255

COC user with  BP 2.0 25.5 319

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COC side effects
• Nausea (upset stomach)- most common
• Changes in bleeding patterns (lighter, irregular,
infrequent or no monthly bleeding)
• Mood changes or headaches
• Tender breasts
• Dizziness
• Slight weight gain or loss

Many women do not have any side-effects. Side-effects often go away after
a few months and are not harmful.

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Who can use COCS
Category 1 and 2 examples:

WHO Category Conditions (selected examples)

menarche to 39 yrs; nulliparous; endometriosis;

endometrial or ovarian cancer; uterine fibroids; family
Category 1 history of breast cancer; varicose veins; irregular,
heavy, or prolonged bleeding; anemia; STI/PID;
hepatitis (chronic/carrier)

≥40 yrs; breastfeeding ≥6 months postpartum;

superficial venous thrombosis; dyslipidaemias without
Category 2 other cardiovascular risk factors; uncomplicated
diabetes; cervical cancer; unexplained vaginal
bleeding; undiagnosed breast mass

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Who should generally not use COCs
Category 3 Examples:

WHO Category Conditions (selected examples)

Category 3
Postpartum:
• Breastfeeding between 6 weeks and 6 months
• Non-breastfeeding and less than 3 weeks if no
additional risk factors for deep vein blood clots (VTE)
• Non-breastfeeding 3-6 weeks with additional risk of VTE

Vascular conditions:
• Hypertension (history of or BP 140-159/90–99)
• Migraine without aura (older than 35 yrs)

Gastrointestinal conditions:
• Symptomatic gall bladder disease (current and
medically-treated)
Drug interactions:
• Use of seizure medications or rifampicin or rifabutin
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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Who should not use COCs
Category 4 Examples:

WHO Category Conditions (selected examples)

Category 4 Breastfeeding: <6 weeks postpartum
Non-Breastfeeding: <3 weeks with risk factors for VTE
Smoking: ≥15 cigarettes/day and ≥ 35 yrs old

Vascular conditions:
• Hypertension (≥160/≥100)
• Migraines with aura
• Ischemic heart disease or stroke
• Diabetes with vascular complications
• Deep venous thrombosis (history or acute)
• Pulmonary embolism (history or acute)

Liver conditions:
• Acute hepatitis
• Severe liver disease and most liver tumors
Breast cancer: current or within 5 yrs
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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COC use by women with HIV
WHO Eligibility Criteria • Women with HIV or AIDS can use
without restrictions
Condition Category
• Women on ARVs can use COCs safely
HIV-infected 1
• Should not be used by women who
AIDS 1 take medications for seizures or
rifampacin or rifabutin for
ARV therapy tuberculosis (may reduce
(which does not
contain ritonavir)
2 effectiveness of COCs)

Ritonavir/ • Using low-dose COCs is appropriate

ritonavir-
• Condom use should be encouraged in
boosted PIs
(as part of ARV
3 addition to COCs
regimen)

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COC use by postpartum women
WHO Eligibility Criteria • Non-breastfeeding women should not
initiate COCs before 3 weeks postpartum
Condition Category
(3-6 weeks postpartum with VTE risk
Non- factors)
breastfeeding 3 • Breastfeeding women
<3 weeks
• Should not use COCs before
Breastfeeding
<6 weeks 4 6 weeks postpartum
• Should not use COCs from
Breastfeeding 6 weeks to 6 months postpartum unless
>6 weeks and <
6 months
3 no other method is available
• Can generally initiate COCs at
6 months postpartum
Breastfeeding
≥6 months 2

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
 When to start COCs - 1
• Anytime you are reasonably certain the woman is not pregnant
• Pregnancy can be ruled out if the woman meets one of the
following criteria:
• Started monthly bleeding within the past 7 days
• Is breastfeeding fully, has no menses and baby is less than 6 months old
• Has abstained from intercourse since last menses or delivery
• Had a baby in the past 4 weeks
• Had a miscarriage or an abortion in the past 7 days
• Is using a reliable contraceptive method consistently and correctly

• If none of the above apply, pregnancy can be ruled out by

pregnancy test, pelvic exam, or waiting until next menses

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
When to start COCs - 2
• If starting during the first 5 days of the menstrual cycle,
no backup method needed
• After day 5 of her cycle, rule out pregnancy and use
backup method for the next 7 days
• Postpartum
• Not breastfeeding: May start 3 to 6 weeks after giving
birth, depending on presence of risk factors for blood
clots
• Breastfeeding: May start 6 months after giving birth

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
When to start COCs - 3
• After miscarriage or abortion
• Immediately, if within 7 days after first- or second-trimester miscarriage or
abortion, no backup method needed
• If more than 7 days after, rule out pregnancy, use backup method for
7 days
• Switching from hormonal method
• May start immediately, no backup method needed (with injectables, initiate
within reinjection window)
• Switching from non-hormonal method
• If starting within 5 days of start of menstrual cycle, no backup method needed
• If starting after day 5 of cycle, use backup method for 7 days
• After using emergency contraceptive pills
• Initiate immediately after taking progestin-only ECPs, use backup method for 7
days
• After taking ulipristal acetate (UPA) ECPs she can start or restart COCs on the 6th
day after taking UPA EPs
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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 How to take COCs
Take one pill each day, by mouth.
If you use the 28-pill pack:
• No waiting between packs.
• Once you have finished all the pills in the pack,
start new pack on the next day.
28-pill pack

If you use the 21-pill pack:

• 7 days of no pills
• Once you have finished all the pills in the pack,
wait 7 days before starting new pack. For
21-pill
21-pill pack
pack example: If you finish the old pack on Saturday,
take the first pill of the new pack on the following
Sunday.
Waiting too long between packs greatly increases risk of pregnancy.
Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
 COCs: Missed pills instructions
Miss 1 or 2 active pills in a row or start a pack 1 or 2 days late:
Always take a pill as soon as possible.
Continue to take one pill every day.
No need for additional protection.

Miss 3 or more active pills in a row or start a pack 3 or more days late:
• Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or
avoid sex for next 7 days. If she had sex in the past 5 days, she can consider ECPs.

AND OR
• If these pills missed in week 3, ALSO skip the
inactive pills in a 28-pill pack and start a new pack week 3

• If the inactive pills are missed, throw away the

missed pills and continue taking pills 1 each day
Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
COCs: Correcting rumors and misconceptions
COCs:
• Do not build up in a woman’s body. Women do not need a
“rest” from taking COCs.
• Must be taken every day, whether or not a woman has sex
that day.
• Do not make women infertile.
• Do not cause birth defects or multiple births.
• Do not change women’s sexual behavior.
• Do not collect in the stomach. Instead, the pill dissolves
each day.
• Do not disrupt an existing pregnancy.

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Management of COC side effects
Counseling and reassurance are key.
Problem Action/Management
Ordinary headaches Reassure client: If side effects persist
usually diminish over time; and are unacceptable to
take painkillers client:
if possible, switch pill
Nausea and Take pills with food or at formulations or switch
vomiting bedtime to another method.

Breast tenderness Recommend supportive

bra; suggest pain reliever

Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/

Management of COC side effects:
Bleeding changes

Problem Action/Management
Irregular bleeding Reassure client: reinforce If side effects persist
correct pill taking and and are unacceptable to
review missed pill client:
instructions; ask about if possible, switch pill
other drugs that may formulations or offer
interact with COCs;
administer short course of another method.
non-steroidal anti-
inflammatory drugs

Amenorrhea Reassure client: no

medical treatment
necessary.

Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/

When to return: Warning signs of rare COC
complications

• Severe, constant pain in belly, chest, or legs

• Very bad headaches
• A bright spot in your vision before bad headaches
• Yellow skin or eyes

Advise to stop taking COCs, use a backup method,

and see a health care provider.
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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
Problems that may require stopping COCs or
switching to another method - 1

Problem Action
Unexplained vaginal • Refer or evaluate by history and pelvic exam
bleeding • Diagnose and treat as appropriate
• If an STI or PID is diagnosed, the client may continue
using COCs during treatment

• If the client develops migraines with or without aura,

Migraines or her migraine headaches worsen, stop COC use
• Help the client choose a method without estrogen

Tell the client she should:

Circumstances that keep
her from walking for one • Tell her doctors she is using COCs
week or more • Stop taking COCs and use a backup method
• Restart COCs 2 weeks after she can move about

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
 Problems that may require stopping COCS or
switching to another method - 2

Problem
Starting treatment with
anti- convulsants or
rifampicin, rifabutin, or
ritonavir
Action
• These drugs make COCs less effective; COCs may
make lamotrigine less effective.
• Advise the client to consider other contraceptive
methods (except progestin-only pills).

Blood clots, heart or liver • Tell the client to stop COC use
disease, stroke, or breast • Give the client a backup method to use
cancer • Refer for diagnosis and care

• Assess for pregnancy

Suspected pregnancy • If confirmed, tell the client to stop taking COCs
• There are no known risks to a fetus conceived while
a woman is taking COCs

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Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/
COCs: Summary
• Safe for almost all women
• Effective if used consistently
and correctly
• Fertility returns without a delay
• Screening and counseling are
essential

Adapted from Training Resource Package for Family Planning: https://www.fptraining.org/

Combined injectable contraceptives
(monthly injectables)

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 What are monthly injectables?
• Monthly injectables or combined injectable contraceptives contain 2
hormones, a progestin and an estrogen, like the natural hormones
progesterone and estrogen in a woman’s body.
(Combined oral contraceptives also contain these 2 types of hormones.)
• They are also called combined injectable contraceptives, CICs, the
injection.

They are available as:

1. Medroxyprogesterone acetate (MPA) 25mg + estradiol cypionate
Cyclofem, Ciclofemina, Ciclofem, Cyclo-Provera, Lunella, Lunelle,
Novafem, Feminena
2. Norethisterone enanthate (NET-EN) 50 mg + estradiol valerate
Mesigyna, Norigynon

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Monthly injectables: Mechanism of action
and effectiveness

Mechanism of action
• Like COCs, monthly injectables work primarily by preventing
the release of eggs from the ovaries (ovulation).

Effectiveness
• As commonly used, about 3 pregnancies per 100 women using
monthly injectables over the first year. This means that 97 of
every 100 women using injectables will not become pregnant.
• Less than 1 pregnancy per 100 women using monthly
injectables over the first year (5 per 10,000 women), when
women receive their injections on time.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Characteristics of monthly injectables

COCs:
• Do not require daily action • Slightly delayed return to
by the user fertility (An average of
about 5 months, one
• Can be used privately month longer than with
• Injections can be stopped most other methods)
at any time
• No protection against
• Good for spacing births sexually transmitted
infections or HIV

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Monthly injectables: Differences from
progestin-only injectables
Compared to progestin-only injectables DMPA or NET-
EN, monthly injectables:
• Contain estrogen as well progestins, that is,
combined methods.
• Contain less progestin
• More regular bleeding, fewer bleeding disturbances.
• Require a monthly injection, whereas NET-EN is
injected every 2 months and DMPA, every 3 months..
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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Monthly injectables: Side effects
• Changes in bleeding patterns
• Lighter bleeding, fewer days of bleeding
• Irregular bleeding
• Infrequent bleeding
• Prolonged bleeding
• Amenorrhea (no monthly bleed)
• Weight gain
• Headaches
• Dizziness Bleeding changes are normal
• Breast tenderness and not harmful.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Monthly injectables: Health risks
and benefits
• Safe and suitable for nearly all women
• Long-term studies are limited
• Benefits and risks similar to those of COCs
o Less effect on blood pressure, blood clotting, lipid
metabolism, and liver function

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Who can and cannot use monthly
injectables
Nearly all women can use monthly injectables safely and
effectively, including women who:
• Have or have not had children • Smoke fewer than 15
• Are married or are not married cigarettes daily and are over
• Are of any age, including 35 years old
adolescents and women over 40 • Have anemia now or had
years old anemia in the past
• Have just had an abortion or • Have varicose veins
miscarriage • Are living with HIV, whether
• Smoke any number of cigarettes or not on antiretroviral
daily and are under 35 years old therapy

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 When to start monthly injectables - 1
A woman can start injectables any time she wants if it is reasonably
certain she is not pregnant (use the Pregnancy Checklist). There is
no need for pregnancy test, any blood tests, other routine
laboratory tests, pelvic examination, cervical screening or breast
examination.
Having monthly bleeding:
• Within 7 days after the start of monthly bleeding, it can be assumed
she is not pregnant. Start injection and no need for a backup
method.
• If after 7 days after the start of her monthly bleeding, rule out
pregnancy before giving injection, use a backup method for 7 days.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 When to start monthly injectables - 2
Postpartum:
• If breastfeeding fully or nearly fully: wait 6 months
• If breastfeeding partially: wait 6 weeks
• If not breastfeeding: anytime within 4 weeks after delivery on days 21- 28 (if
additional risk for VTE, wait until 6 weeks), no need for backup (after 4 weeks,
rule out pregnancy and use backup methods for 7 days).
After miscarriage or abortion: anytime within 7 days
(after day 7 rule out pregnancy and use a backup method for 7 days).
When switching from another method: start immediately if
reasonably certain she is not pregnant. No need for a backup
method. If switching from another injectable, give the new injectable
when the repeat injection would have been given.
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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 When to start monthly injectables - 3
After taking emergency contraceptive pills (ECPs):
• Progestin-only or combined ECPs:
• Start or restart injectables on same day as taking the ECPs or
anytime after ruling out pregnancy. Use a backup method for 7
days after the injection.

• After taking ulipristal acetate (UPA) ECPs:

• Start or restart injectables on the 6th day after taking UPA-ECPs or
anytime after the 6th day after ruling out pregnancy. Use a back
up method from the day of taking UPA-ECPs until 7 days after the
injection.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Monthly injectables: Managing late
injections

Less than 7 days late for a repeat injection:

• Give next injection. No need for tests,
evaluation, or a backup method.

More than 7 days:

• Give next injection if she has not had sex 7
days after the injection was due or she has
used a backup method or taken ECPs if she
had. Use a backup method for 7 days after
the injection.
• If not, rule out pregnancy before giving the
next injection.
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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Monthly injectables: Correcting
misconceptions
Monthly injectables:
• Can stop monthly bleeding, but this is not harmful; blood
does not build up inside the woman
• Do not make women infertile
• Do not cause early menopause
• Do not cause birth defects or multiple births
• Do not cause itching
• Do not change women's sexual behaviour

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Monthly injectables: Management of side effects

Problem Action/Management
Irregular • Reassure her that many women using monthly injectables
bleeding experience irregular bleeding. It is not harmful and usually
becomes less or stops after the first few months of use.
• For modest short-term relief, suggest 800 mg ibuprofen 3
times daily after meals for 5 days, or other nonsteroidal
anti-inflammatory drug (NSAID), beginning when irregular
bleeding starts.
Heavy or • Reassure; suggest NSAID beginning when heavy bleeding.
prolonged
bleeding • To help prevent anemia, suggest iron tablets and tell her
eating of foods containing iron.
No monthly • Reassure, this not harmful. It is similar to not having
bleeding monthly bleeding during pregnancy. She is not pregnant
or infertile. Blood is not building up inside her.

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

Monthly injectables: Management of side effects

Problem Action/Management

Weight gain • Review diet and counsel as needed.

Ordinary
headaches • Reassure and suggest pain relievers; evaluate headaches
(nonmigrainous) that worsened after starting injectables.

Breast • Recommend that she wear a supportive bra (including

tenderness during strenuous activity and sleep).
• Try hot or cold compresses.
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg),
paracetamol (325–1000 mg), or other pain reliever.
• Consider locally available remedies.
Dizziness
• Consider locally available remedies.

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

 Monthly injectables: New problems that may require switching
methods
Problem Action/Management
Unexplained • Refer or evaluate by history and pelvic examination.
vaginal bleeding Diagnose and treat as appropriate.
(that suggests a • She can continue using monthly injectables while her
medical condition is being evaluated.
condition not • If bleeding is caused by sexually transmitted infection or
related to the pelvic inflammatory disease, she can continue using monthly
method) injectables during treatment.
Migraine • Regardless of her age, a woman who develops migraine
headaches headaches, with or without aura, or whose migraine
headaches become worse while using monthly injectables,
should stop using injectables.
• Help her choose a method without estrogen.
Starting • Combined hormonal methods, including monthly
treatment with injectables, can make lamotrigine less effective. Unless she
lamotrigine can use a different medication for seizures than lamotrigine,
help her choose a method without estrogen.

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

 Monthly injectables: New problems that may require switching
methods
Problem Action/Management
Circumstances • If she will be unable to move about for several weeks, she
that will keep her should:
from walking for – Tell her doctors that she is using monthly injectables.
one week or more – Stop injections one month before scheduled surgery, if
possible, and use a backup method during this period.
– Restart monthly injectables 2 weeks after she can move about
again.
Certain serious • Do not give the next injection.
health conditions
including • Give her a backup method to use until the condition is
suspected heart evaluated.
or liver disease • Refer for diagnosis and care if not already under care.
• Assess for pregnancy.
Suspected • Stop injections if pregnancy is confirmed.
pregnancy • There are no known risks to a fetus conceived while a woman
is using injectables

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

Monthly injectables: summary
• Safe for almost all women
• Effective if used consistently and correctly - Coming
back every 4 weeks is important for greatest
effectiveness.
• Injection can be as much as 7 days early or late.
• Screening and counseling are essential

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

Combined patch
What is the combined patch?

• A small, thin, square of flexible plastic

worn on the body.
• Continuously releases 2 hormones, a
progestin and an estrogen which are
like the natural hormones
progesterone and estrogen in a
woman’s body, directly through the
skin into the bloodstream.
• Also called Ortho Evra and Evra.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: Mechanism of action

• Works primarily by preventing the release of eggs from

the ovaries (ovulation).
• The woman puts on a new patch every week for 3 weeks,
then no patch for the fourth week. During this fourth week
the woman will have monthly bleeding.
• No delay in return of fertility after patch use is stopped.
• Does not provide protection against sexually transmitted
infections.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: Effectiveness
• As commonly used, about 7 pregnancies per 100 women using
the combined patch over the first year. That is, 93 of every 100
women using the combined patch will not become pregnant.

• When no mistakes are made with use of the patch, less than 1
pregnancy per 100 women using a patch over the first year (3
per 1,000 women).

• Pregnancy rates may be slightly higher among women

weighing 90 kg or more.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Combined patch: Side effects

• Skin irritation or rash where the • Vomiting

patch is applied • Breast tenderness and pain
• Changes in bleeding patterns: • Abdominal pain
– Lighter bleeding and fewer • Flu symptoms/upper
days of bleeding respiratory infection
– Irregular bleeding • Irritation, redness, or
– Prolonged bleeding inflammation of the vagina
– No monthly bleeding (vaginitis)
• Headaches
• Nausea

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: Known health benefits
and health risks

• Long-term studies of the patch are limited, but

researchers expect that its health benefits and risks
are like those of combined oral contraceptives.

59

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

Combined patch: Who can start and when
to start

• Medical eligibility criteria guidelines for when to

start and helping continuing users for the combined
patch are the same as for combined oral
contraceptives and the combined vaginal ring.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: Late replacement or
removal, or patch comes off - 1
Forgot to apply a new patch after the 7-day patch-free interval or late
changing patch at the end of week 1 or 2:
• Apply a new patch as soon as possible and keep the same patch-
change day.
• If late by only 1 or 2 days (48 hours or less), there is no need for a
backup method.
• If more than 2 days late (more than 48 hours), use a backup method
for the first 7 days of patch use. The new patch will begin a new 4-
week patch cycle, and this day of the week will become the new
patch-change day.
• If more than 2 days late and unprotected sex occurred in the past 5
days, consider taking emergency contraceptive pills.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: Late replacement or
removal, or patch comes off - 2

Late taking off the patch at the end of week 3:

• Remove the patch.
• Start the next cycle on the usual patch-change day.
• No need for a backup method..
The patch came off and was off for less than 2 days (48 hours or
less):
• Apply a new patch as soon as possible. (The same patch can be
re-used if it was off less than 24 hours.)
• No need for a backup method.
• Keep the same patch change day.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: Late replacement or
removal, or patch comes off - 3

The patch came off and was off for more than 2 days (more
than 48 hours):
• Apply a new patch as soon as possible, use a backup method
for the next 7 days and keep the same patch-change day.
• If during week 3, skip the patch-free week and start a new
patch immediately after week 3. If a new patch cannot be
started immediately, use a backup method and keep using it
through the first 7 days of patch use.
• If during week one and unprotected sex occurred in the past
5 days, consider taking emergency contraceptive pills.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined patch: summary
• Health benefits and risks are like those of combined
oral contraceptives.
• Replace each patch on time for greatest effectiveness.
• No delay in return of fertility after patch use is
stopped.
• Screening and counseling are essential

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

 Combined
vaginal ring
 What is the combined vaginal ring?
• A flexible ring that a woman places in
her vagina.

• Continuously releases 2 hormones, a

progestin and an estrogen which are
like the natural hormones
progesterone and estrogen in a
woman’s body, from inside the ring.

• Hormones are absorbed through the • Also called NuvaRing

wall of the vagina directly into the
bloodstream.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined vaginal ring: Mechanism
of action
• Works primarily by preventing the release of eggs from the
ovaries (ovulation).
• The woman leaves the ring in her vagina for 3 weeks, then
removes it for the fourth week. During this fourth week the
woman will have monthly bleeding.
• No delay in the return of fertility after ring use is stopped.
• No protection against sexually transmitted infections.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined vaginal ring: Effectiveness

• Depends on the user. Risk of pregnancy is greatest when a

woman is late to start a new ring.

• As commonly used, about 7 pregnancies per 100 women

using the combined vaginal ring over the first year. That is,
93 of every 100 women using the combined vaginal ring will
not become pregnant.

• When no mistakes are made with use of the combined vaginal

ring, less than 1 pregnancy per 100 women using the
combined vaginal ring over the first year (3 per 1,000
women).

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined vaginal ring: Side effects
• Changes in bleeding patterns, including:
– Lighter bleeding and fewer days of bleeding
– Irregular bleeding
– Infrequent bleeding
– Prolonged bleeding
– No monthly bleeding
• Headaches
• Irritation, redness, or inflammation of the vagina (vaginitis)
• White vaginal discharge

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Combined vaginal ring: Known health
benefits and health risks
• Long-term studies of the vaginal ring are limited.

• Researchers expect that its health benefits and

risks are like those of combined oral
contraceptives.

• Evidence to date has not shown adverse effects.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined vaginal ring: Who can start
and when to start

• Medical eligibility criteria, guidelines for

when to start, and helping continuing users
for the combined ring are the same as for
combined oral contraceptives and the
combined patch.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined vaginal ring: Late replacement
or removal - 1
Left ring out for 48 hours or less during weeks 1 through 3:
• Put the ring back in as soon as possible, no need for a backup method.

Left ring out for more than 48 hours during weeks 1 or 2:

• Put the ring back in as soon as possible and use a backup method for the next 7
days.
• If the ring was left out for more than 48 hours in the first week and unprotected sex
occurred in the previous 5 days, consider taking emergency contraceptive pills.

Left ring out for more than 48 hours during week 3:

• Put the ring back in as soon as possible and use a backup method for the next 7
days.
• Start a new ring at the end of the third week and skip the ring-free week. If unable
to start the new ring at the end of the third week, use a backup method and keep
using it through the first 7 days after starting a new ring.

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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Combined vaginal ring: Late replacement
or removal - 2
Forgot to insert a new ring at beginning of the cycle:
• Insert a new ring as soon as possible. If late by only 1 or 2 days (48 hours or
less), that is, the ring is left out no longer than 9 days in a row, no need for a
backup method. Keep the same ring removal day.
• If the new ring is inserted more than 2 days (more than 48 hours) late, that is,
the ring is left out 10 days or more in a row, use a backup method for the first
7 days of ring use.
• If unprotected sex occurred in the past 5 days, consider taking emergency
contraceptive pills.

Kept ring in longer than 3 weeks:

• If the same ring is used for up to 28 days (4 weeks), no backup method is
needed. She can take a ring-free week or start a new ring immediately.
• If the same ring is used for 28 to 35 days (more than 4 weeks but less than 5
weeks), insert a new ring and skip the ring-free week. No backup method is
needed.
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Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
Combined vaginal ring: summary
• Health benefits and risks are like those of combined
oral contraceptives.
• Start each new ring on time for greatest effectiveness.
• No delay in return of fertility after patch use is
stopped.
• Screening and counseling are essential

Family Planning: A Global Handbook for Providers (3rd Edition, 2018)

 75
Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Acknowledgement
This training presentation was adapted from the following
resources:

• Training Resource Package for Family Planning

https://www.fptraining.org/

• World Health Organization Department of Reproductive Health

and Research (WHO/RHR) and Johns Hopkins Bloomberg School
of Public Health/Center for Communication Programs (CCP),
Knowledge for Health Project. Family Planning: A Global
Handbook for Providers (2018 update). Baltimore and Geneva:
CCP and WHO; 2018. Available from:
https://www.fphandbook.org/
76
 Additional resources
• •
• WHO Medical Eligibility Criteria
(MEC) for Contraceptive Use, Fifth
edition. WHO, 2015. Available
from:
http://www.who.int/reproductiveh
ealth/publications/family_planning
/MEC-5/en/
WHO Selected Practice
Recommendations for
Contraceptive Use (3rd edition
2016). WHO, 2016. Available from:
http://www.who.int/reproductive
health/publications/family_planni
ng/SPR-3/en/
Implementation Guide for the
Medical Eligibility Criteria and
Selected Practice
Recommendations for
Contraceptive Use Guidelines.
WHO, 2018. Available from:
http://apps.who.int/iris/bitstream
/handle/10665/272758/97892415
13579-eng.pdf?ua=1

• For all the latest publications on family planning visit:

https://www.who.int/reproductivehealth/publications/family_planning/en/ 77